PRACTICAL CONSIDERATIONS : THE TESTICLES. 1951 



In its bearing on the development and course of hernia and inflammation the 

 relation of misplaced testicle to the peritoneal pouch, which accompanies it, is of 

 great importance. This pouch may remain open, communicating freely with the gen- 

 eral peritoneal cavity, thus enhancing the probability of the formation of hernia or of 

 the extension of inflammation ; it may be closed above but open below the testicle, 

 favoring the development of hydrocele ; it may be obliterated. Exceptionally, espe- 

 cially when the testicle is retained but the vas has partly or completely descended, 

 the funicular process of the peritoneum may extend as an open pouch to the bottom 

 of the scrotum, thus allowing a hernia to pass far beyond the position of the retained 

 testis. 



Occasionally the testicle is found in the front of the scrotum (the epididymis 

 anterior and the vas deferens in front of the other constituents of the cord), as if it 

 had made a semi-revolution on its vertical axis (inversion of the testicle). The pos- 

 sibility of the existence of this anomaly emphasizes the propriety of determining by 

 palpation and by the test of translucency the position of the testicle before tapping 

 for hydrocele ; or, if these fail, of evacuating the fluid by incision instead of with a 

 trocar. 



Torsion (axial rotation) of the testicle, including the spermatic cord, also on 

 its longitudinal axis, is an accident which usually affects imperfectly descended tes- 

 ticles, but is not confined to them. The cause is probably a congenital malformation, 

 since, as Owen has pointed out, a testis properly placed in the scrotum and possessed 

 of a normal mesorchium cannot be twisted. The twist may be in either direction, 

 to the right or to the left, and in accordance with its extent and the degree of con- 

 striction to which the vessels are subject the symptoms are slight or severe. In slight 

 cases the epididymis alone becomes infiltrated. In severe cases the entire gland with 

 the epididymis becomes gangrenous. 



Orchitis as distinguished from epididymo-orchitis is rare as a result of either 

 trauma or infection, owing to the firm support the gland receives from the tunica albu- 

 ginea and to the free movement of the testicle, not only within its serous tunic, but 

 also within the scrotum, and, on the other hand, to the fact that septic organisms 

 gaining access to the ejaculatory duct, or brought to the gland in the general circula- 

 tion, are in either case arrested and given the opportunity to multiply in the neigh- 

 borhood of the epididymis. 



The intimate investment of the testicle by the tunica vaginalis, which is complete 

 except at the point of entry and emergence of the vessels at its posterior border, but 

 which leaves the whole hinder aspect of the epididymis without a serous covering, 

 determines the frequency with which serous effusion (acute hydrocele) occurs in 

 contusions or inflammations of the testicle proper as compared with those of the 

 epididymis. 



The similar close investment of the former by the tunica albuginea accounts for 

 the relatively greater pain and slower swelling in orchitis. It also brings about, when 

 by ulceration a communication with the cutaneous surface has been established, the 

 slow protrusion of the swollen and infected testicular substance, known as hernia or 

 fungus testis, analogous to hernia or fungus cerebri, the physical conditions enclo- 

 sure of peculiarly soft and yielding tissue within a dense and resisting membrane 

 being similar in the two instances. The sickening pain following contusion of the tes- 

 ticle, or often associated with orchitis, is due to pressure upon or irritation of testicu- 

 lar nerves which, by way of the spermatic plexus, communicate with the aortic and 

 solar sympathetic plexuses. A similar communication with the renal plexus explains 

 the testicular pain and retraction accompanying the passage of a renal calculus. The 

 primary development of the testicle in the vicinity of the tenth dorsal vertebra has 

 determined its chief innervation from the tenth dorsal segment of the cord (Head) 

 and thus its relation to the posterior divisions of the lower dorsal and the lumbar 

 nerves which causes the ' ' backache' ' so commonly felt in orchitis, in the presence of 

 a solid tumor of the testicle, or after injecting the sac of a hydrocele. The epididy- 

 mis derives its nerve-supply chiefly from the pelvic plexus, which also supplies the 

 vas deferens and the seminal vesicles. As it communicates with the spermatic plexus, 

 the same symptoms may be associated with an epididymitis ; but as swelling is less 

 resisted and pressure is therefore less, and as the communication with the great 



